Introduction

Mental health problems are highly prevalent in Australia. The National Survey of Mental Health and Wellbeing (2007) reported that as many as one in five Australian adults experienced a common mental disorder (anxiety, affective, substance use) in the previous 12 months [1]. These figures do not include more severe mental illnesses that are less common such as bipolar disorder, schizophrenia, and schizoaffective disorders. However, in 2007 almost half the adult population met the criteria for a least one mental disorder of any type in their lifetime [1]. In addition, there is an unknown number of people with sub-threshold mental health problems that do not meet the criteria for a disorder diagnosis within the standard classification systems. Recent estimates suggest that 0.45% of Australians between the ages 18 to 64 accessed public mental health services for a psychotic disorder [2].

Despite this high prevalence, many people do not receive adequate treatment for mental illness or problematic mental health symptoms. There are a range of reasons for this, which include factors related to delayed diagnosis and treatment—such as availability of mental health services, ability of primary care practitioners to identify psychological symptoms, and a person’s beliefs and attitudes to treatment of mental health symptoms3 and their level of health literacy [4]. Early identification and treatment of mental health symptoms is critical to prevent the development of more serious disorders developing. The increasing prevalence of mental health disorders and inadequate treatment rates has led to mental health becoming a National Health Priority Area of the Australian government (http://www.aihw.gov.au/ national-health-priority-areas/), as the impact of mental illness on both individuals and the broader Australian society is significant. For example, it is estimated that 13% of the total burden of disease in Australasia is attributed to mental and behavioural disorders, and as many as 31% of Australians receiving a disability support pension had a mental illness as their primary diagnosis [2].

Herbal medicine use for mental health

Many Australians use complementary medicines (CMs), such as herbal and nutritional supplements, and other mind-body therapies, for mental health problems. Current prevalence rates are unknown; however, having a mental health condition has been found to predict CM use, with over 70% of CM users reporting a mental health condition in 2007/2008 [5]. Herbal and nutritional medicines are reported to be commonly self-prescribed by people with depressive disorders [6], and anxiety symptoms [7]. Despite the growing popularity of using herbal medicines for mental health, relatively few people consult with practitioners who are trained in prescribing herbal medicines.

Consultations with herbal medicine practitioners for mental health

Despite the prevalence of common mental disorders, as few as 34.9% of people with either a anxiety, affective, or substance use disorder consulted with a health practitioner for their mental health in the previous 12 months in 2007.3 A recent study found that general practitioners (87%) were the most frequently consulted health practitioners by Australian adults who experienced anxiety symptoms in the previous 12 months, which compared to 4.8% and 12% consulting Western herbalists and naturopaths respectively [7]. Similar results were reported for people using CAM for depressive disorders.6 One Australian study found that only 30% of women with self-reported depression sought help for their symptoms, with 22% consulting a herbalist or naturopath [8].

Reasons for low rates of consultations with naturopaths and herbalists may be related to practical barriers such as cost and accessibility, a preference for self-care of mental health problems [9], and inter-personal factors such as discrimination and stigma related to their health care decisions (e.g. some CAM practitioners may be discouraging of conventional treatments) [10]. In addition, both the public and health practitioners have reported that being able to identify a suitably qualified herbal medicine practitioner is confusing [11], which is likely to prevent referrals from conventional health practitioners and deter people from seeing herbal medicine practitioners. These are additional barriers for people experiencing mental illness who may also experience discrimination and stigma from health practitioners related to their mental health [12].

The mental health care system in Australia

The mental health care system in Australia constitutes a broad range of services that are either residential or community based. This section will focus on community based consultation services for less severe mental illness, which includes both primary and allied health providers that deliver specialist mental health services (e.g. psychologists and psychiatrists), and general health services that incorporate mental health care, such as general practitioners (GPs). Naturopaths and herbalists are not currently considered mental health service providers within the mental health care system [13].

Funding for mental health consultation services is provided through the Medicare Benefits Schedule (MBS). It is estimated that there was an increase in use of consultation services from 37% in 2007 to 46% in 2010, which occurred following the introduction of the Better Access scheme, which provided Medicare rebates for specific mental health services [14]. This increase in use of services is solely attributed to the Better Access scheme [14]; therefore, it is clear that cost is a critical barrier to accessing mental health consultation services.

In 2013-2014 there were approximately 17 million consultations with general practitioners that were related to mental health, which is estimated to be 13% of all GP consultations [2]. The most frequently managed mental health problems by GPs were depression, anxiety and sleep disturbance, which accounted for the majority of mental health problems managed by GPs [2].

The role of herbal medicine practitioners in the management of mental health

While people are accessing GP services for their mental health a significant number of people do not respond to conventional treatments for anxiety (>30%),15 or depression (>50%) [16]. These non-response rates suggest that providing alternative treatment options is critical. As there is an increasing evidence-base for the effectiveness of herbal medicines in common mental illnesses such as anxiety [17] and depression [18], herbal medicines are an important treatment option. In addition to having effective therapeutic tools, the holistic philosophies used by naturopaths and Western herbalists align with the national standards for the principles of recovery-oriented mental health practice [19]. Consequently, naturopaths and herbalists have the potential to play an important role within integrative mental healthcare that facilitates a more inclusive, holistic approach that emphasises the importance of prevention and wellness [20].

Barriers to herbal medicine practitioners treating mental illness

While herbal medicine practitioners potentially have an important role to play in the mental health care system, there are a number of barriers to achieving this. Little is currently known about how naturopaths and herbalists are managing mental health problems in clinical practice. Anecdotal evidence suggests that some naturopaths and herbalists do not have an adequate understanding of how best to manage mental health problems using an evidence- based approach to practice. This shortfall in knowledge is likely related to a number of factors currently outside the control of individual practitioners, which include inadequate undergraduate training in mental health, lack of regulation of naturopaths and herbalists, lack of integration with the mental health care system, and inadequate research translation specifically related to best practice in mental health care. Other barriers within the control of individual practitioners include increasing inter-professional communication with other mental health care providers, and ensuring good mental health literacy through postgraduate education. Addressing these barriers is critical to ensure herbal medicine practitioners can assist people to make safe and effective treatment decisions related to their mental health.

Conclusion

Given the challenges for herbal medicine practitioners described there is a need to determine a way forward to ensure that naturopaths and herbalists can help facilitate good mental health care; therefore, the following needs to be considered:

For practitioners

Ensure positive consultation experiences by focusing on patient-centred care and shared decision-making. Regardless of the treatment beliefs of individual health practitioners, clients’ beliefs and values need to be respected without judgment, which aligns with the patient-centred approach. A patient-centred approach with shared decision-making is considered best practice in mental health care [21].

Ensure adequate mental health literacy. Being able to determine the severity of mental health symptoms is a necessary skill for practitioners treating mental health problems so they can determine when to refer to other more suitable health practitioners [10]. Therefore, herbal medicine practitioners need adequate training in managing mental health problems within their scope of practice. Additional post-graduate training may be needed.

Establish networks with other types of mental health practitioners to ensure the most effective patient outcomes. Mental health problems can be complex and require a team approach to care that reflects a truly integrative approach to treatment.

Be aware of the mental health services available to clients. Being able to provide clients with treatment options is critical to provide the best opportunity for recovery.

Ensure the use of reliable scientifically validated assessment tools to monitor treatment outcomes. These may include both biomedical and psychological assessments. Additional training may need to be considered to ensure competency.

Understand scope of practice and limitations of knowledge and training. Not advertising as a “specialist” in mental health unless you have met the requirements for this title (e.g. accredited postgraduate training). Having experience in treating some mental health problems does not make a naturopath or herbalist a specialist in mental health.

Future research, education, and policy considerations

Determine how naturopaths and herbalists are managing mental health problems in clinical practice. Given the lack of standardised training, it is currently unknown if herbal medicine practitioners are adequately trained in mental health [11,22,23]. Therefore, gaps in practitioner knowledge need to be identified. This would allow for improvement in undergraduate curriculums and professional development programs.

Creation of postgraduate training opportunities. There are currently no accredited postgraduate courses in mental health specifically targeted to naturopaths and herbalists.

Research needs to determine the quality of the working relationships between conventional mental health and naturopathic/herbal medicine practitioners, specifically how these health care providers are referring to each other. While there is some movement in conventional medicine towards an integrative approach to mental health care [20], there is a dearth of research exploring how these professions work together, and how they can improve their approach to collaboration. Working together as an integrative health care team is in the best interests of the individual and provides them with more health care choice.

Whole systems research is needed to explore the effectiveness of naturopathic and herbal medicine practitioner prescribing for mental health symptoms in clinical practice. Very few studies have attempted this type of study design [24]. This research approach is crucial given the dearth of research on the effectiveness of prescribing by naturopaths and Western herbalists in general, and specifically for a range of mental health problems.

Integration of naturopaths and herbalists into mainstream mental health care. Ensuring access to a variety of evidence-informed treatment options for people experiencing anxiety aligns with the principles of recovery from mental illness by ensuring consumer choice [21]. Access to herbalists and naturopaths is currently limited to people who have the financial means to access these services.

National regulation of Western herbalists and naturopaths is needed to ensure protection of the public, and minimum standardised education requirements for these practitioners [5, 11, 25-27].

Are you a naturopath or herbalist? What are your thoughts on your role in the management of mental health?